A Case of Accidental Autoerotic Death by Hanging Linked to Erotic Photography

Autoerotic death, as a subtype of mechanical asphyxia, refers to a person's fatal outcome while engaging in solitary sexual activity using various devices and methods to reduce oxygen supply and induce cerebral hypoxia, leading to increased sexual gratification. These asphyxial deaths are accidental and sporadic. In cases of sexual asphyxia, especially when strangulation methods such as hanging or ligature are used, thorough crime scene investigation is crucial to determine the type of asphyxia and the manner of death. Inadequate information about specific crime scene findings can lead to significant errors in determining the manner of death and the type of strangulation, potentially leading to cases being mistaken for ligature strangulation in a homicidal manner or hanging in a suicidal manner.


Introduction
"Asphyxia" as а term leads its origin from the Ancient Greek and means "absence of pulsation" [1].It is commonly used in modern forensic medical practice and refers to death or different types of health disturbances due to oxygen deficiency in the organs and tissues.There are many different ways of classifying asphyxial death.In the field of forensic medicine, mechanical asphyxia is a condition characterized by the physical obstruction of the airways (from the mouth and nose to the alveoli) of different etiologies that prevents breathing and leads to the inability to utilize oxygen at the cellular level.Autoerotic death or autoerotic asphyxia as a subtype of mechanical asphyxia refers to the fatal outcome of an individual having different types of sexual activities, usually by using different techniques and methods, intending to reduce the oxygen volume inside the body.This pathological condition of decreased volume of oxygen produces cerebral hypoxia with the final result increasing sexual gratification [2][3][4][5][6].Case reports, similar to the present one, are accidental as the manner of death, and they are extremely uncommon in routine forensic practice.
This article was previously presented as a meeting abstract at the Balkan Academy of Forensic Sciences (BAFS) Annual Scientific Meeting on September 24-27, 2021.

Case Presentation
In 2021, a female discovered the body of her 26-year-old son, who had hanged himself in his apartment.The mother explained that when she went to the address, she noticed a scarf sticking out from the outside of the entry door.When she opened the door, she found her son lying on the floor with a ligature around his neck (Figure 1).The ligature was fixed and made by a cotton scarf and a towel, tied together at their ends with a single knot (Figure 2).The loose end of this self-made "rope" has been secured to the entrance door.The external view of the cadaver at the crime scene showed well-presented postmortem lividity on the anterior surface of the whole body, with a well-defined bluish color.Only the upper part of the body was covered with clothes (a black T-shirt), and socks were present in the area of the feet.In addition, the protrusion of the tongue was observed, as well as body fluids in the area of the penis, resembling semen.
A switched-on computer with erotic pictures on the screen was also found at the scene (Figure 3).A death  Immediately after the crime scene examination, the body was transported for routine forensic examination to determine the manner, the mechanism, and the cause of death.During the autopsy, the external examination of the body showed one well-defined, slightly depressed, negative imprint of the ligature, with an oblique course, above the thyroid cartilage in the upper part of the neck.The depth of the ligature mark was better presented on the anterior surface of the neck; at its backside, the ends were meeting together (Figure 4 and Figure 5).The ligature mark was circumferential.No other traumatic injuries were stated during the external examination of the body.

FIGURE 5: The ligature mark during the autopsy procedure
The internal examination showed that the brain had severe congestion and edema (Figure 6), weighing 1430 g with a few petechial hemorrhages of the white matter.

FIGURE 6: General view of the brain with edema
The right lung weighed 670 g, and the left lung 600 g, with a few petechial hemorrhages on the surface (see Figure 7).The heart weighed 310 g and showed mild atherosclerosis in the heart blood vessels.Pinpoint hemorrhages were found over the mucosa of the internal organs during the examination, and the blood in the major blood vessels was dark red and liquid.

FIGURE 7:
The lungs present with severe congestion, edema (black arrows), and petechial hemorrhages (white arrows) over their surface In addition, the abdominal organs were presented with severe congestion; the liver weighed 1700 g, the spleen 310 g, and the kidneys 130 g each.Organ samples were preserved for histological examination, and based on it, well-presented edema of the brain and lungs was observed with stasis in the internal organs.The microscopic examination of the tissues corresponded to the cause of death, asphyxia.The chemical analysis of blood showed no alcohol or drug concentrations.

Discussion
In cases of autoerotic asphyxia, most commonly when death occurs, it is associated with different pathological mechanisms of asphyxiation aimed at achieving a single goal, sexual gratification.Based on this, the synonyms of this type of death are the following terms: asphyxiophilia, hypoxyphilia, or just sexual asphyxia [7,8].The estimated annual incidence of sexual asphyxia varies in different countries: in the United States, there are 2-4 cases per one million; in Scandinavia, 1-2 cases per one million; in Canada, 0.2-0.5 cases per one million; in Australia, 0.3 cases per one million; and in Sweden, 0.14 cases per one million [9].The most commonly used methods resulting in asphyxia are hanging, strangulation, suffocation via plastic bags, and chest compression [6].Less commonly reported cases include the inhalation of volatile gases, autoerotic drowning, and fatal electrocution during sexual arousal attempts [3,7,[10][11][12][13][14][15].Autoerotic asphyxiophilia is often bound with other paraphilias such as transvestism [13], pictophilia, and bondage.This can explain the great range of devices and props found in the crime scene in such cases, including pornographic magazines and photographs, pain-stimulating agents, intimate feminine garments, ropes, bondage, locks, chains, condoms, and rubber items [16][17][18].
Usually, in cases of autoerotic asphyxia, there is a so-called rescue or release mechanism, which allows the person to release the pressure and reduce the level of hypoxia [2,19].In the present case, the rescue mechanism was the door handle.In these cases, death usually occurs when this escaping mechanism fails for some reason, such as a technical issue or the person's inability to react appropriately, due to the wrong perception associated with some kind of intoxication (alcohol-or drug-related) or due to the fast loss of consciousness.In cases of autoerotic strangulations, an important role in the fatal outcome is the mechanism of vagal nerve inhibition and the irritation of the carotid sinus, which leads to sudden cardiac arrest and rapid loss of consciousness.As this type of sexual behavior is a private act, family members often find out about this accidentally, when death occurs, as seen in the present case.Out of shock and shame, family members can change the scene and cover up some of the traces that would lead to a correct diagnosis [3,5].In these cases, determining the manner, the mechanism, and the cause of death can be a difficult, even impossible, task.In such cases, several important points of action should be performed, experienced medicolegal death investigation personnel should supervise the crime investigation, and the proper inspection of the cadaver should be performed at the scene.The information provided by the relatives at the crime scene should be critically evaluated and should be compared to the forensic evidence based on the examination of the body at the crime scene and during the autopsy.A comprehensive investigation of the location, a full autopsy, and toxicological examinations are also mandatory components of a thorough case investigation [20].

Conclusions
Autoerotic asphyxia is a dangerous act in which an individual intentionally restricts their own oxygen supply.This behavior can have life-threatening consequences.When investigating cases of sexual asphyxia, especially those involving strangulation by hanging or rope, it is crucial to thoroughly examine the scene of death.Insufficient data about the specific findings at the scene can result in serious forensic errors when determining the type and manner of asphyxia-related death.These errors could lead to the misclassification of cases as ligature strangulations (homicides) or hangings (suicides), which may have significant negative consequences in investigative and legal proceedings.

FIGURE 1 :FIGURE 2 :
FIGURE 1: The crime scene depicts the position of the corpse at the time of its discovery

FIGURE 3 :
FIGURE 3: Erotic photograph seen on the computer screen of the deceased